NOTES-Assisted Trasvaginal Splenectomy: The Next Step for the Minimal Invasive Approach to the Spleen

Laparoscopic splenectomy (LS) is the gold standard for treatment of normal-medium sized spleens, but spleen morcellation and removal requires an enlargement of the wound port, specially for extraction of the intact spleen. Transvaginal extraction of the resected spleen was described in early 90’, but rarely used, and it didn’t avoid the use of multiple large diameter trocars (3-5 of 5-12 mm) trough the abdominal wound. NOTES description have favored hybrid less invasive approaches to the abdomen, but it has not been applied for spleen pathology. The Aim of this videopresentation is to show the technique used for a hybrid NOTES assisted transvaginal splenectomy: Case report and surgical technique: A 65 yrs. woman, multipara, without previous abdominal surgery diagnosed of a 6 cm multicystic splenic lesion. BMI: 30. Surgical steps: 1.- : Preoperative planning: Body CT in right lateral decubitus and 3D body reconstruction measuring the distance from the tip of the vagina to the splenic hilum (27,5 cm) . 2.- Table position: Patient placed in right decubitus with free access to the vulvar introitus. 3.- Pneumoperitoneum and 3 subcostal mininstruments ports (1 of 5 mm and 2 of 3 mm). 4.- Transvaginal 15 mm trocar insertion under laparoscopic control (5 mm scope), 5.- Insertion of a 13 mm colonoscope transvaginally for control of the dissection of the spleen with the subcostal instrumentation (Ucision and 3 mm instruments). 6.- Transvaginal stapling transection of the splenic hilum with standard flexible tip 60 mm extralong (44 cm) endostapler (Ethicon). 7.- Insertion transvaginally of a bag (Endocatch II, Covidien) to recover the spleen, and extraction trough the Douglasl pouch. 8.- Closure of the vagina. Operative time was 180’, with uneventful recovery and discharge at 48 hrs. Conclusion: Transvaginal acces can be safely used for operative visualization, hilum transection and spleen removal, reducing at minimum the parietal wall trauma. Clinical, esthetic and functional advantages require further analysis.